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Wednesday, May 25, 2011

How I Spent My Day, most of it good, some of it stupid (E and M codes)

Today started early because I was being the hospitalist as well as the stress test doctor as well as my usual identity as primary care physician. A hospitalist is a doctor who takes care of all of the patients in a hospital who have no other doctor or whose doctor doesn't take care of patients in a hospital. It is a fine job, as it is practiced in many larger communities, though it limits the doctor's ability to make long term connections with patients, who usually see someone else when they are not confined to a hospital. People who take hospitalist jobs work shifts, make a fixed salary and get lots of time off.  In our small town, the hospitalist is my long suffering partner, nearly all of the time, but I and my other internal medicine colleagues spell her evenings and weekends and occasional vacations. We all squeeze our hospital work into a day that also includes outpatient primary care medicine.

As the hospitalist I had 6 patients to see before clinic started at 10, only 2 of them really critically ill, and because this is my week for doing stress tests, I had two other people to supervise while we used various methods to stress their hearts to see if they had coronary artery disease. The stress tests are a great joy because I get to meet new people and hear their stories and give them health advice while they are open to it. While they are walking or being injected there is nothing else I need to be doing, no computers to interact with, at least not in a distracting way, and no distractions. There is plenty of time to find out who they are and maybe help them make a slight detour if their lifestyle and habits are heading them in a deadly direction.

After nearly 25 years of medical practice, most things I do are rewarding. There are exceptions, however.  Most exceptions fall into the category of things I can't do well.  If there is something I don't know about or physically am not skilled enough to do, I can find a colleague to help. The most difficult situation, though, is when it is necessary to be in two places at the same time, or do two (or three) things in an inadequate amount of time. When situations like this arise, I begin to be annoyed by inefficient processes.

The New England Journal of Medicine published an article this week about one of the stupid processes upon which we physicians, those of us involved in fee for service medicine, waste our time. 

here is the link:

When I see my patients in the hospital, I just estimate the time and complexity of my services and bill accordingly. When I do stress tests, I am paid by the hour. When I see patients in the office I must calculate their bill based on Evaluation and Management Codes, introduced for the first time in 1991. These codes are an attempt to calculate the value of a medical service based on various pieces of information that can be documented in a patient's chart. If I document a very complete history and include a physical exam of several parts of the patient's body that is exhaustive, I can bill a 99214, which will pay me substantially more than a 99213 which still requires quite a bit of documentation. If I do everything imaginable in the appointment and document that, I can bill a 99215. This is the king of the outpatient bills and pays the most money.  If I document that I spent an hour talking to the patient, I can legally bill a 99215, but if I work really fast and ask a whole bunch of questions and poke and prod every part of my patient and that patient is pretty complicated, I could potentially get 2, 3 or even 4 99215's in an hour. But by law if I bill a 99215 and I don't document that I did all of the little things I was supposed to to qualify for a 99215, I can be heavily fined or even arrested. (Legal sanctions apply only to Medicare and Medicaid billing, but E and M coding is used pretty much universally by all insurers.)

So today, like every day, despite the fact that today was plenty crowded with people who needed my attention, I spent a significant amount of precious time making sure that I documented (typed up, clicked on) enough elements for my outpatients that my billing would stand up to scrutiny should I be audited.  My electronic medical record is built to help me with my E and M coding, but because it is so geared to coding, it is not nearly as good at concisely expressing what I did with my patient.  I can review the patient's family history and social situation, but if I don't include the verbiage, which may be identical to the verbiage I documented last week, my documentation will be inadequate to bill for the complex and time consuming interaction and I will need to charge less than the appointment was worth. The time I spend polishing my documentation is time that I can't see sick patients. It also, more insidiously, affects the way in which I care for my patients and what my brain is doing when I am with them. It is vital for the survival of my office that I make enough money to support my nurses and receptionists, pay my rent and eventually support my family. So I, like all other fee for service physicians, play the E and M game. I am mostly unable to get payment for any of the rest of the work that I do, such as telephone management or written communications, so E and M coding of my face to face patient interactions pays for everything else I do.

When the various codes were introduced in the early 90s, many of us objected to the changes, but now we are so accustomed to spending our time and brain cells to categorize our work in this way that very few people even realize what an impact this has on our quality of service.  Robert Berenson MD, Peter Basch MD and Amanda Sussex MPH who wrote the New England Journal article are the first to publicly complain about this system for years.  Improvements in billing including streamlining the coding has been suggested, but instead it will soon be getting even more complex. Truly the best solution to the foul and tangled web of medical billing will be significant payment reform. Calls for the end of fee for service medicine have been increasingly common, and as far as I'm concerned, it can't happen soon enough.

Wednesday, May 18, 2011

How death panels can save your life and other stories

The Annals of Internal Medicine occasionally reviews the articles and studies of note in a particular field of internal medicine for those of us who don't read all of the specialty journals. This month there was an update in pulmonary and critical care medicine, the internal medicine specialty that is most intimately involved with caring for the very ill and those people who are at the ends of their lives. Nestled among articles on diagnosis of tuberculosis and novel treatments for non-small cell lung cancer is one about palliative care, that is medical interventions intended to make people more comfortable as they die.

This article, published in the New England Journal of Medicine by Dr. J.S. Temel and colleagues from the Massachusetts General Hospital in Boston, looks at quality and length of life in patients with recently diagnosed incurable lung cancer, cancers that have spread metastatically beyond the lung tissue.  These patients cannot expect to be cured of their cancers, but will be offered many treatments intended to lengthen their lives and shrink their tumors. About half of the patients were offered visits early in their treatment with the palliative care team, to discuss what kind of treatment they wanted at the end of their life, including resuscitation and life support, but also pain and other symptom control. The other group received standard treatment, which might include palliative care, but usually not until life prolonging therapy was found to be ineffective. The patients assigned to early palliative care consultation received less intensive treatments as they were dying, but they also had a significantly better quality of life and they lived longer.

An article like this doesn't explore the individual stories of the people who were involved, but I'm thinking those stories would be pretty interesting. Without those stories, one can only speculate what made the early palliative care group happier and healthier. My speculations would include that it was comforting to patients to know that they would be well taken care of and their suffering would be relieved when it was their time to die. Other factors might include family members being reassured by open conversations about the end of life, leading to better care at home and more contact with doctors who are good listeners and take the time to really discuss the patient's and family's concerns.

It is also interesting to note that the group with early palliative care, though receiving less intensive medical interventions at the end of life, lived longer than those with more intensive interventions. Intensive care was not "rationed" as frightened legislators might think, but rather used appropriately for the individual.

The whole discussion of death panels sort of escaped me when it came around the first time and when it has recurrently resurfaced. End of life discussions have always been a part of practicing good medicine, and it would be nice to be paid for them specifically so that more physicians would take the time to do them properly.  A panel of physicians would not be particularly good at talking to people about death and so a death panel, even if it weren't just a figment of a paranoid imagination, would be terribly inefficient. One of my patients, a 90 year old woman, expressed fear of death panels several months ago, and after explaining that I wasn't sure where that idea had sprung from, we had a good, simple and productive talk about what kind of therapy was available to her should her heart stop or her other functions cease to be, and we were able to document exactly what she would want should she not be able to express her wishes. 

As doctors who frequently admit patients who normally see other doctors to the hospital, my partner and I are often on the receiving end of the problem of inadequate discussions of end of life wishes.  Very ill or dying patients will be admitted to the hospital, with one of us as their doctor, and have never discussed with anyone what kind of care they would want.  They are often too sick by that time to talk about it or think about it, and even if they were capable, they don't know me or my partner from Adam, and reasonably don't have the level of trust necessary to allow us to help them make a good decision. This leads to heartache and wasted effort.

So what I see as the take home message of this New England Journal article is that discussions of end of life preferences including life support but also ways to receive comfort do not need to be depressing, but can be affirmations of life's value and our own self determination. When a doctor opens up this area for a person and his or her family to talk about, fears can be allayed and options can be explored. Death is just about always difficult in some way or another, but there are many ways to handle it that help to maintain our love and humanity.

Monday, May 16, 2011

My TED Talk

The Technology, Education and Design group was founded in 1984 in Monterey, California, to promote ideas that primarily related to information systems. Since that time, the focus has expanded and now includes subjects of global relevance as expressed in their mission statement: ..."We believe passionately in the power of ideas to change attitudes, lives and ultimately, the world. So we're building here a clearinghouse that offers free knowledge and inspiration from the world's most inspired thinkers, and also a community of curious souls to engage with ideas and each other."

TED talks have been criticized as being elitist and as reducing scientists and scholars to circus performers, but having watched several of them, I think that the discipline of having to express ones most important ideas in 18 minutes in a format that can be understood by just about everyone is a great idea. As far as elitist, I suppose that probably applies, since it is unlikely that anyone who is not well spoken and at least moderately well known will have the opportunity to speak. I, for instance, will not be invited. Which is why I will write my TED talk up on my blog rather than waiting for a phone call from whoever it is who telephones those who are worthy. There are TEDMED talks as well, which are about my field, but all of those folks are in some way hugely famous having won prizes, written books or earned honorary degrees. They talk about fascinating subjects, but so far I don't see anybody writing about whyamericanhealthcareissoexpensive.

A TED talk is kind of like a super-slow motion elevator speech. It involves both the idea to be explained and a mini-biography of the person with the idea, as a way of giving the idea a human setting. In that way, a TED talk is different from a church sermon and different from a college lecture.  Here goes:

Half my life ago I became interested in practicing medicine. I came from a relatively well educated family, but not a medical one. My mother had painfully limited her choices by never finishing college. For me, medicine offered the opportunity to nurture while being financially and in many other ways independent, after paying the reasonable price of several years of indentured servitude. Besides the requirement for independence, my family had given me a powerful message of the value of frugality. As I moved further into my training in medicine I was frequently troubled by what looked like waste. I was trained at the Johns Hopkins School of Medicine, one of the most well respected medical schools in the world, so I withheld judgement about what seemed to be excessive use of testing and medications. I entered practice over 20 years ago, and saw a more haphazard use of technology, and experienced the system of cooperative managed care as practiced in my first job as a general internist at Group Health in Everett, Washington. There, certain expensive resources were jealously guarded, but other ones were used even when inappropriate. When I moved away to a private practice setting, I learned how efficient I could be by getting to know my patients well and discussing options with them for evaluation and treatment. As the years went on, there were even decision trees to help decide on the best alternatives, though those did not always represent my patients' needs.

Frugality was offended, however, when my patients were referred to specialists or ended up in the emergency department due to sudden changes in their health.  In these places tests were ordered without a second thought and medications prescribed without conversations about costs or alternatives. One day after a CT scan ordered by another physician showed a confusing but not very concerning finding on a patient who had far too many medical tests due to her inability to express herself well, the radiologist and I, while speaking on the phone together, simultaneously said "I could lower healthcare costs 30% tomorrow." We had simultaneously become so frustrated with the way medicine was practiced that it was no longer a discussion about this particular patient, but of the whole way tests, procedures and medications were ordered.

Not long after that, in the heat of debates about what to do with an American health care system that fails to offer even marginal care to millions of low and middle income citizens, I began to do rough math to determine exactly how much money was being wasted on unhelpful, unnecessary and potentially harmful testing and treatment on a regular basis.  By practicing medicine as a primary care physician often does, it is more than possible to waste 10s of thousands of dollars a day, without even considering the overuse of more expensive procedures such as surgeries and prescription of medical contraptions of dubious utility that goes on outside of my areas of expertise. 

This overuse of unnecessary medical interventions is primarily due to the long standing fee for service system in much of medical practice, in which a physician is paid not for keeping a person healthy, but often just the opposite, seeing them or doing things to them. Humans in general want to be healthy, happy and live a long time, then be allowed to die in peace and comfort. So much of medicine is not in any way furthering those aims. In addition to fee for service, third party payment (insurance policies paying for medical care) protects physicians from free market forces, since patients don't have any direct interest in the cost of their medical care and insurance companies can and do simply pass on outlandish costs to insurance consumers as premiums.  A CT scan, for instance, costs much more in the US than in other countries and is used much more frequently, at a cost of 10s of thousands of lives every year from radiation exposure and with no proven benefit in many cases.

The fear of being sued for malpractice is more than a small influence on these issues, though lack of incentive to reduce costs is much more important.  Certainly physicians are sued if a cancer is discovered at an advanced stage when a well timed CT scan or other procedure could have saved a life, however much of the drive to sue for malpractice is based on becoming impoverished by medical costs and due to dissatisfaction with physicians, all of which can be traced to an inefficient and non-patient centered approach to medical care.

The third party system is also a fierce temptation to commit fraud.  Complex billing schemes make a patient's bill nearly impossible to interpret, and so it is rare for a patient to question a bill in any way that is effective.  An insurance company paying the bill may have an incentive to  make sure billing is honest, but the insurance company employee investigating a bill has no actual knowledge of what service was performed and a very difficult time tracing whether such a service was appropriate.  I'm not sure whether there is a theorem that states that where fraud is possible it is occurring at the rate that is just slightly below the system's ability to detect it, but there should be. Huge amounts of money are inevitably being outright wasted due to fraudulent billing.

So what is the simple solution to all of this?

Physicians could simply start thinking of cost as an issue when prescribing testing, procedures, medications or medical devices. This should not be the only consideration, but in a world in which resources are limited, it is absolutely necessary that cost be part of the discussion. These discussions should be between the physicians and their patients, taking into account all of the issues.  Patients also need to begin to take some responsibility for health care costs, participating in shared decision making in a well considered way. 

The third party fee for service system of payment for medical care must go.  Without direct connection of costs to good outcomes, those costs will continue to rise without any appropriate value.  A physician who is paid a set amount to keep a patient healthy will have much more incentive to practice cost-effective care than one with a blank check and no other motivation to do well than his or her own ethical belief system.  A system that combines the successes of staff model health care cooperatives with the personal touch and intimate contract of concierge medicine can provide those incentives at a fraction of the cost of providing the inadequate care we have now.  Eliminating fee for service medicine will help push physicians to use all of the networking technology available to communicate with patients in a way that is most convenient and effective for both parties.

The system of civil suits for malpractice needs to be significantly changed. Presently malpractice suits take years to be resolved, end up with angry patients and angry physicians, ruin lives and careers and often provide no compensation for an injured party. Suits contribute to physician burnout and attrition, which further worsens access to primary care. A good system would compensate patients quickly for injury and target hospitals and responsible physicians for improvement of knowledge, attitudes and systems to prevent further injury. No fault systems have been effective elsewhere, and mediation has already had a big impact on compensation for medical injury in the US. Quick compensation outside of the court systems should be the rule, not the exception in the US.

It has been a great pleasure to be able to practice medicine for nearly 25 years. I have been privileged to share the stories of countless people, to share their lives, meet their families, and to interact with physicians and nurses who combine compassion with humor and ungrudging hard work.  There is much that is caring and good about the practice of medicine as it is now. The nearly 20% of our gross domestic product that goes into the provision of medical care, even when wasted on tests, procedures, drugs and contraptions that are not helpful, is still contributing to our economy instead of that of China.  There is much to be grateful for. However there is also much that can be done to better focus all of this effort and money so that the millions of people who are suffering due to the inadequacies of our system are better served.

Monday, May 9, 2011

Lifeline Screening, prevention and early detection of disease

Most of what we think of as preventive medicine is actually not that at all. Mammograms, pap smears, colonoscopies, all of these are actually early detection of disease. Abnormal results on any of these tests prompts more testing and sometimes treatment, which may or may not result in better health or a delay in becoming ill or dying.  True prevention of disease would include healthy diet, exercise, accident prevention, safe sex and adequate birth control. These are the kinds of things that truly keep people from getting sick, but most of these are not truly in the scope of care provided by physicians.

Today I got a letter in the mail from a company called Life Line Screening, inviting me to "participate in a simple potentially lifesaving screening to assess...risk for stroke, abdominal aortic aneurysms and other vascular diseases."  There will be a bunch of ultrasound technicians in a nearby community center who will be eager to check my blood vessels for narrowings, and my abdominal aorta for widening, which might indicate an aneurysm.  Any of these tests would cost me $60, but I can get all of them, 5 tests for $159. The tests will be run by technicians and read by qualified physicians and I will get my results in a few weeks. As far as the money costs, this is not at all a bad deal.  Any of these tests if done in our hospital would cost much more than the total cost of $159, though I would receive my results more quickly and the level of detail would be considerably higher. The only hitch is that I don't actually need any of these tests, and it is likely that my health related anxiety will be significantly higher than my baseline as I wait for the results.

The US funds a task force to determine which tests contribute to lengthening life and improving its quality, called the United States Preventive Services Task Force (USPSTF.) This group uses the data from many clinical trials to determine who should get which testing and at what frequency in order to maximize health. It turns out that routine screening for breast cancer before the age of 40 (or 50 in the case of low risk women) probably causes more harm than good. Prostate cancer screening for men with no symptoms is also in this category. Screening for prostate cancer in a man who is over the age of 75 is definitely a bad idea, leading to more, not less death and disability than no screening. Vascular procedures such as done by Life Line Screening are mostly not helpful in making us healthier, with a few exceptions and a handful of caveats.

Screening for abdominal aortic aneurysms is definitely a good idea in men over the age of 65 who have ever smoked. This is widely enough accepted that Medicare now pays for it without any co-pay. So if I were the right person to get this test, I would not have to pay anything for it, and my doctor could order it from any hospital that I preferred. Screening for atrial fibrillation and peripheral arterial disease should be a normal part of any physical exam, and ultrasound testing for these things may not add any significant accuracy. Checking the carotid arteries for narrowing is not shown to reduce the incidence of stroke, though it can raise a person's consciousness of the need to reduce vascular risk. The final test offered by Life Line is an ultrasound of the bones of the heel to check for osteoporosis, but that is a really poor test for detecting the strength of important bones, and with expanded insurance coverage for preventive services, most insurances, and definitely Medicare, cover a better test, called the DEXA scan, without any co-pay in appropriate patients.

But all this said, I am not entirely against Life Line screening.  I find that the act of scheduling this testing, showing up, and receiving the results in the mail is an important first step for patients that heads them in the direction of taking better care of their health. The community event of having this company come to a church or gymnasium brings people together to talk about health and focus on what might be ways they can postpone or prevent actual disease. For patients who have no regular doctor and receive no medical or prevention advice, either because of lack of money or of motivation, an abnormal result on a screening test such as this may be a very important piece of information.

Another issue that is very interesting here is that pretty sophisticated testing can be provided much less expensively than in hospitals or doctors' offices. How can it be that this company can do an ultrasound of my carotid arteries for less than 1/10th the cost that my local hospital would charge me? The answer gets back to two major factors that increase cost of American health care: liability (the cost of malpractice suits) and third party payment systems (health insurance). Because the company that does this screening does not bill insurance companies and because patients pay up-front for their care, the care is inexpensive. An ultrasound machine and the services of a technician are not very expensive, and the physicians that read the exams can do so very quickly since the scope of the exams is limited. The process does not involve a doctor-patient relationship and refers all patients back to their primary care physician, so they are not liable to the kinds of lawsuits that drive up physicians' fees. The overwhelming popularity of Lifeline Screening and programs like it demonstrate that Americans are very motivated to receive medical care that is slightly substandard if the cost is reasonable. This is not an option being offered to patients by our present health care system. When the American consumer wanted an affordable automobile, the model T was created. In medical care, we seem only to be able to come up with a newer and fancier Mercedes Benz.

Bottom line? If a person has a good doctor, he or she doesn't need a set of 5 Life Line Screening tests. There is no evidence to suggest that getting these done in addition to regular physicians' care will lengthen life or reduce disability. The fact that many of us do not have regular physicians' care due to the cost and difficulty of even having access to a doctor ensures that programs like this will continue to be popular and profitable.

Monday, May 2, 2011

How is concierge care different from capitation?

Long ago in the late 1900s, that is to say not long after I got out of my residency, wise people had the idea that medical care would be more affordable if patients had a primary doctor who would be paid to take care of that patient and who would act as a gatekeeper to specialty physicians.  Because specialty care was so expensive and often use of specialists fragmented medical care, a patient would see his or her primary doctor before being referred to the cardiologist or the surgeon or the dermatologist.  Emergencies were exempt from this process. The physician would be paid a flat fee, per year, to take care of each patient. Patients became dissatisfied with this model, feeling that it impinged on their autonomy, and doctors didn't like either the gatekeeper role, or the fact that, in situations where patients were unexpectedly sick, the system of capitation could lead to financial hardship for the physician. Managed care and capitation are not gone, but the words have developed negative connotations and these models are practiced only in a limited manner, often in health care coops such as Group Health or Kaiser.

Now, however, more and more doctors are opting out of fee for service and payment by insurance companies and opening "concierge" services, in which a patient will pay a certain sum of money in return for better than average primary care, including cell phone and e-mail access to the doctor and longer appointments.  The doctor is able to offer these services because eliminating the hassles of insurance billing means that the doctor can make just as much money treating significantly fewer patients.  Concierge practices run from low cost to high cost, with an average yearly fee of about $1500. Both patient and physician satisfaction is high in these practices.

So what is different about this than a capitated system of payment? Nothing, I think, other than that the contract in concierge medicine is entirely between the doctor and the patient, without a middle man or organization.  The patient decides for him or herself whether the price the doctor charges is worth the services offered.

There is some animosity that surrounds doctors with concierge practices, as they are accused of only offering care to patients who can afford to pay their fees out of pocket.  I wonder, however, how the out of pocket costs compare between traditionally insured patients and concierge patients.  I'm thinking that those costs are probably not that different, and that they might at times favor the concierge patients. 

As we shift our ideas of how medical care should be delivered, I think we need to consider the strengths of concierge medicine and combine its characteristics with concepts of capitation and managed care to capture the successes of both.  One of the most important issues is to keep patients involved in defining what care they find valuable.  No matter how we pay for medical care, it comes down to the fact that the costs are paid from the pockets of the patients, and so they should have direct input on determining what kind of medical care they receive.